What is meant by “complementary feeding?” What are the factors to be considered in complementary feeding? What are the benefits of breast milk as the baby begins to learn to eat new foods and liquids? Do mothers encounter difficulties when they begin to introduce new foods into the exclusively breastfed baby’s diet?
The second topic to be addressed by the Breastfeeding Topic of the Month website is Complementary Feeding, which is any foods that provide nutrients and that are given in addition to breast milk, prepared at home or commercially.
While there is increasing evidence that women are breastfeeding less and less, there is also international concern when the introduction of complementary foods is delayed. A mother or other caregiver might find it difficult to determine when or how to begin feeding a breastfed baby with complementary foods and might put off the decision. Cultural beliefs can also interfere, as the variety of foods is huge. Family interference, particularly when the mother starts to leave the baby with another caretaker, must also be considered.
In any case, postponing the introduction of complementary foods past a certain time can jeopardise the growth and development of a child.
Breast Milk Provides for Infant Needs
It is known that breast milk provides all the infant needs for about the first 6 months, and that it can contribute in some populations, with half (50%) of the energy requirements in the second semester of a child’s life, and one third (around 30%) in the second year. Therefore, although it is generally agreed that children should continue to be breastfed at least until the second year of life, international agencies (WHO/UNICEF) also recommend that after 6 months, all children should get complementary foods, in addition to breast milk.
What Different Agencies/Organisations Say about Complementary Feeding
La Leche League International (http://www.lalecheleague.org/) – Young babies do best without the early addition of solids to their diet. Human milk is the perfect food for at least the first 6 months for the healthy, full-term infant, and there is usually no reason for adding any foods to the breastfed baby’s diet before that time. (Womanly Art of Breastfeeding, 1997, page 231)
World Health Organisation (http://www.who.int/)– during the 1990s, recommendations of the World Health Assembly have been issued regarding appropriate age to begin complementary feeding: Resolution 43.3 (1990) mentions the age range of 4 to 6 months as a transitional period to allow breast-fed infants to adjust to consuming solid foods; In 1992, Resolution WHA 45.34 affirms: “from the age of about 6 months infants should begin to receive a variety of locally available and safely prepared foods rich in energy, in addition to breast milk, to meet their changing nutritional requirements” . The sentence “from about 6 months” was repeated in Resolution WHA 47.5. It is also important to mention that WHO had previously issued a resolution in 1986 affirming that no follow-on milks are necessary as part of complementary foods, but preferably family food. (Please refer to the exclusive breastfeeding topic for further information on this.)
American Academy of Paediatrics (http://www.aap.org/) – Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. Infants weaned before 12 months of age should not receive cow’s milk feedings but should receive iron-fortified formula. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet. (Breastfeeding and the Use of Human Milk, 12/97 RE9729)
LINKAGES (USAID funded breastfeeding project)( www.linkagesproject.org/) has a publication “Facts for Feeding. Guidelines for Appropriate Complementary Feeding of Breastfed Children 6-24 months of Age” that is very informative.
Nursing Mothers Association of Australia (http://www.nmaa.asn.au/) — Breastmilk provides all the baby ‘s nutritional needs for the first six months of life; – It is still the most important food for the first 12 months;- It is important to watch for signs that the baby is ready for solids; – For the first 12 months solids should be seen as a complement to breastmilk rather than meeting all the nutritional needs of the baby. (Breastfeeding Management in Australia, NMAA, 1997, Edited by Wendy Brodribb , “Chapter 5, Introduction of Solids”)
Studies are not always consistent, but a recent and important one, carried out in Honduras, showed no advantage of complementation before 6 months, in terms of growth. Actually, other food or fluid in diet was shown to decrease the amount of energy provided by breast milk.
When the infant starts receiving complementary foods, the main concern should be the nutrient/energy density and bioavailability of the nutrients of the foods provided, the frequency of meals, and the amount of food eaten per meal. There are also other factors in the complementary food intake: appetite, monotony, taste and viscosity and the caretaker’s behaviour. It is a good idea to test different samples before to choose a brand (http://www.formybaby.org).
The Readiness Factor
The readiness to accept solid foods should be assessed. Not all babies will be ready for solids at the same age. Some will be ready to start earlier than 6 months, while others will not be ready for solid foods until later in the second half of the first year. Some babies who are susceptible to food allergies may even refuse solids until 8 or 9 months of age. The mother should be aware of her baby’s overall health and weight gain and offer solid foods periodically (every few days) until the baby is interested.
Signs of Readiness
Before a mother begins to introduce solid foods to her baby, it is recommended that she look for “signs of readiness.” These signs would include the baby’s ability to sit up or support his own back and head, a reduction in the tongue-thrust reflex (the baby does not automatically push the spoon out of his mouth), some hand to mouth skills and an increased demand to nurse that is not related to illness or teething (Breastfeeding Answer Book, LLLI, 1997).
Nutrient Requirements, Calories and Density
Consideration should be given to the possible lack of micronutrients (iron, vitamin A, zinc, calcium, vitamin B6, B12, iodine, selenium etc) in the common foods eaten in a given community. For the breastfed infant, human milk will be enough in terms of vitamins in the mother’s nutrition, although a mother may change her habits during the time she is breastfeeding (a vegetarian versus a non-vegetarian, for instance).
If the child is taking less breast milk from the sixth month on, the energy content required of the complementary food received will increase from 270 Kcal/day during 6-8 months to 450 and 750 Kcal/day at ages 9-11 and 12-23 months respectively. The variety and quantity, therefore, will be essential to meet the child’s nutritional requirements for growth and development.
The energy density that is provided by the complementary foods will depend on the different patterns of breast milk intake and the child’s age. At a minimum, complementary foods should provide 0.70Kcal/g. For this reason, usually fruit juices, vegetables or soups are not recommended, because they have a very low energy density.
Factors Involving the Child
The reduced gastric capacity of the infant (30-40 ml/Kg) is another factor in fulfilling the energy requirements of the child. The frequency of complementary foods to be offered to a child should vary according to the energy density of the food chosen.
Regarding the proteins in complementary food content, it is important to consider quality and digestibility, being more appropriate to choose proteins of animal origin, due to the growth needs in early childhood. A vegetarian diet can provide high quality protein if sufficient and appropriate combinations of plant-based foods are ingested.
Iron, Calcium and Vitamin A
IRON: how much of iron is absorbed and available to the metabolism is the main concern in the complementary foods chosen. Iron from vegetable origin is not well-absorbed (1-6%) compared to iron from animal origin (up to 22%). Also, the presence of other nutrients such as ascorbic acid (oranges, other citric, etc) enhance iron absorption from meat, fish, etc. Iron is less absorbed from egg yolk, animal milk, tea or coffee. High density of iron is found in liver and beef; low density of iron (and low bioavailability) is typical in animal milk and its by-products. If iron requirements are not overestimated, it is recommended the mother provide the child complementary foods enriched with iron, or iron supplementation.
CALCIUM: As with iron or zinc, animal products also provide higher density and bioavailability of calcium. On the other hand, different foods interfere in calcium absorption such as oranges and other citrics, and some fibers found in cereals or fruits. Bioavailability of calcium is reduced in a vegetarian diet. A good recommendation to fulfil calcium requirements is milk products and fish. It is Important to point out that animal milk in natura is not recommended due to the risk of intestinal microhemorragy and contamination.
VITAMIN A – Human milk has sufficient Vitamin A if the mother’s diet is rich in this micronutrient. If not, it is recommended to supplement the mother with Vitamin A.
Giving Foods – Before or after the Baby Breastfeeds?
Internationally, there is no consensus yet on whether complementary foods should be fed to the child before or after he/she has breastfed.
We have prepared a document with some additional information on complementary feeding and encourage you to read it, as well.